Focus
Authors: Daniel Shouval
Journal: Journal of Hepatology (2013)

How to improve care in outpatients with cirrhosis and ascites: A new model of care coordination by consultant hepatologistsJournal of HepatologyVol. 59Issue 2PreviewThe development of ascites in patients with cirrhosis is associated with a high rate of health care utilization. New models of specialized caregiving support are necessary to optimize its management. The aim of the study was to evaluate the efficacy and financial sustainability of the “Care management check-up” as a new model of specialized caregiving support based on a series of diagnostic facilities performed in real time and on the integrated activity of consultant hepatologists at the hospital unit for outpatients, dedicated nurses, physicians in training and primary physicians, compared to standard care in outpatients with cirrhosis and ascites. Full-Text PDF Cirrhosis is a leading cause of death worldwide. The rising global burden of cirrhosis and its complications is the focus of much attention in Europe, the US and elsewhere [1Runyon B.A. Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012.Hepatology. 2013; 57: 1651-1653Crossref PubMed Scopus (526) Google Scholar, 2European Association for the Study of Liver EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis.J Hepatol. 2010; 53: 397-417Abstract Full Text Full Text PDF PubMed Scopus (1327) Google Scholar]. In the US, it is the eighth leading cause of death affecting approximately 5.5 million patients at an annual cost of >$1.5 billion [[3]Kim W.R. Brown Jr., R.S. Terrault N.A. El-Serag H. Burden of liver disease in the United States: summary of a workshop.Hepatology. 2002; 36: 227-242Crossref PubMed Scopus (497) Google Scholar], which is expected to rise further in the next 10 years due to aging hepatitis C populations [[4]Davis G.L. Alter M.J. El-Serag H. Poynard T. Jennings L.W. Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression.Gastroenterology. 2010; 138 (21 e1–6): 513-521Abstract Full Text Full Text PDF PubMed Scopus (775) Google Scholar]. A similar trend is observed in Western Europe [[5]McAvoy N.C. Hayes P.C. The cirrhosis epidemic in the UK: evaluating the causes in a European context.Expert Rev Gastroenterol Hepatol. 2007; 1: 41-45Crossref PubMed Scopus (13) Google Scholar]. About 50–60% of patients with compensated cirrhosis will develop ascites within a decade at a 5-year survival rate of ∼50% (excluding liver transplant patients) [6Gines P. Quintero E. Arroyo V. et al.Compensated cirrhosis: natural history and prognostic factors.Hepatology. 1987; 7: 122-128Crossref PubMed Scopus (886) Google Scholar, 7Gines P. Cardenas A. Arroyo V. Rodes J. Management of cirrhosis and ascites.N Engl J Med. 2004; 350: 1646-1654Crossref PubMed Scopus (665) Google Scholar]. Patients with cirrhosis are prone to develop a number of often predictable and treatable, but costly, complications including ascites, spontaneous bacterial peritonitis (SBP), renal failure and hepatic encephalopathy [[8]Volk M.L. Tocco R.S. Bazick J. Rakoski M.O. Lok A.S. Hospital readmissions among patients with decompensated cirrhosis.Am J Gastroenterol. 2012; 107: 247-252Crossref PubMed Scopus (314) Google Scholar]. Up to 69% of patients with decompensated cirrhosis required at least one non-elective hospital readmission within a median time of about two months to the first admission [[8]Volk M.L. Tocco R.S. Bazick J. Rakoski M.O. Lok A.S. Hospital readmissions among patients with decompensated cirrhosis.Am J Gastroenterol. 2012; 107: 247-252Crossref PubMed Scopus (314) Google Scholar]. Consequently, such patients with decompensated cirrhosis require close and specialized medical care. Regretfully, the quality of care given to such patients is at best suboptimal. A recent study by Kanwal et al. measured quality of care indicators in 774 patients with cirrhosis and ascites [[9]Kanwal F. Kramer J.R. Buchanan P. et al.The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs.Gastroenterology. 2012; 143: 70-77Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar]. The results of this survey suggest that only 33% of patients received all guidelines recommended care, with quality scores ranging from 30% for secondary prophylaxis of SBP to 90% for cell counts in the ascitic fluid. Moreover, only 30% of patients with SBP were prescribed antibiotics for secondary prophylaxis within 30 days of discharge and only 49% of patients with bleeding esophageal varices received prophylactic antibiotics. The reasons for the failure of the healthcare system to provide better care to these patients are further discussed in an editorial by M. Volk, written in response to the publication by Kanwal et al. [9Kanwal F. Kramer J.R. Buchanan P. et al.The quality of care provided to patients with cirrhosis and ascites in the Department of Veterans Affairs.Gastroenterology. 2012; 143: 70-77Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar, 10Volk M.L. How can we improve quality of care for patients with cirrhosis?.Gastroenterology. 2012; 143: 17-19Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. As with other medical conditions, the quality of care for patients with cirrhosis is mainly driven by the knowledge and competence of both the primary care physician and the hepatologist as well as the patient’s compliance, but, not less important, by the structure of the healthcare system. Quoting Dr Volk in his editorial ‘How can we improve quality of care for patients with cirrhosis’ [[10]Volk M.L. How can we improve quality of care for patients with cirrhosis?.Gastroenterology. 2012; 143: 17-19Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]: “The majority of the deficit may lie in the structure of our healthcare system which is episodic, symptom driven and reactive rather than proactive and better suited for treating acute issues than chronic conditions…”. In the present issue of the Journal, Dr Morando and co-workers from Padua, address the need for improvement in the structure of the health care system for cirrhotic patients with ascites [[11]Morando F. Maresio G. Piano S. et al.How to improve care in outpatients with cirrhosis and ascites: a new model of care coordination by consultant hepatologists.J Hepatol. 2013; Google Scholar]. The authors suggest a new model for specialized care giving for ambulatory cirrhotic patients with ascites (which most probably is also applicable to other complications of decompensated liver disease) which leads to a significant reduction in the 12-month mortality as well as the overall cost of care. Briefly, 100/110 candidate patients with cirrhosis and ascites were recruited consecutively and were allocated in an alternate, non-randomized fashion upon discharge from hospitalization to either a newly designated “care management check-up” group (group 1), N = 40; or to a “standard of care” outpatient group (group 2), N = 60. Groups were matched for age, gender, type of ascites, MELD score, CTP score, etiology of cirrhosis, place of residence and co-morbidities based on the Charlson index. Group 1 was followed by a team of hepatologists and dedicated nurses at a hospital outpatient clinic. They had rapid, same day access to specialized procedures as well as blood and urine test including ultrasound, gastroscopy, EEG, and psychometric testing. Based on same-day-obtained results of the investigation (hospital stay of 5–9 hours), patients received specific dietary and pharmacologic instructions; were rescheduled for a new clinic visit within 1–12 weeks and the new results and recommendations forwarded to the primary care physician. Group 2 (the control group) patients were referred after hospital discharge to the general, primary care practitioner, to be followed and treated according to existing guidelines with potential support “on demand” from a specialized physician. Laboratory tests and interventional procedures were available to this group through elective appointments. Patients from both groups had access to a day hospital for invasive procedures including banding/ligation of varices, parcentesis or transfusion. The main results of this study reveal that the 12-month mortality in group 2, who had no direct access to specialized care, was almost twice as high as compared to group 1, reaching 45.7% and 23.1%, respectively (p<0.025). Furthermore, hospital readmission rates were more than twice higher for group 2, reaching 42.4% vs. 15.4% in group 2 and 1, respectively. Finally, the overall cost for management per patient-month of life was about 50% lower for group 1, reaching 1479 Euro as compared to 2816 Euro for group 2 (p <0.05). The costs for the specialized care given to group 1, as well as costs for coverage of day-hospital, were significantly higher as compared to the conventional group 2. However, the costs for hospital stay including emergency readmission of group 2 were higher as compared to group 2, thus the global expense was higher for group 2. The conclusions of the study by Morando et al. suggest that the management model for group 1, which requires the placement of a dedicated specialized team for care of cirrhotic patients with ascites, can delay complications, improves quality of life and survival, and is cost effective. Thus, the results of this study provide some answers to the questions raised in the editorial by M. Volk, suggesting a change in the structure of medical care offered to cirrhotic patients using a preemptive pro-active approach. It is still not clear if the conclusions regarding overall cost effectiveness fit only the Italian healthcare system or are applicable in other countries with a different healthcare system structure or specialized day care facilities for patients with liver disease. In some countries, financial coverage for ambulatory care and hospitalization is funded by different insurance providers and such fragmentation will require better coordination between agencies to reach a similar cost saving outcome. In other countries (i.e., Israel), some specialized outpatient clinics and day care facilities are restricted by the insurer in ordering elective investigations in the hospital, such as endoscopy, ultrasound examination, or special blood tests in stable patients whom they prefer to evaluate in their own facilities. However, regardless of these bureaucratic hurdles and some limitations mentioned by the authors in the discussion, the results of this study provide convincing evidence that the Italian model from Padua, of specialized and rapid management of cirrhotic patients with ascites with easy access to diagnostic facilities and counseling, contributes significantly to the quality of life and one-year survival of patients with cirrhosis and ascites. The author declared that he does not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.